Clinical Appeals Review and Compliance Specialist

MedImpact Healthcare Systems, Inc.•San Diego, CA

22h•$108,515 - $196,412•Onsite

About The Position

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team! Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare. At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution! The Clinical Appeals Review & Compliance Specialist, directly reports to the Appeal and Grievance Supervisor, Clinical Programs serving as a clinical and operational support resource for the Appeals Clinical Team. This position is responsible for reviewing Appeals for commercial and Part D, rendering determinations based on established clinical guidelines, plan criteria, regulatory requirements, documented procedures, and clinical judgment. The Clinical Appeals Review & Compliance Specialist assist the clinical team with appeal processing questions and issue resolution, tracking assigned work queues, identifying volume fluctuations, and communicating workflow concerns to management for direction. The Clinical Appeals Review & Compliance Specialist works closely with the Appeals and Grievances Supervisor, Clinical Programs and the Management Team to identify and escalate identified issues, and provide feedback regarding process observations encountered during routine case review activities. Responsibilities include, but not limited to, providing clinical training activities as assigned, support implementation of appeal process updates under Management direction, and completing other operational tasks as determined by Supervisor.

Requirements

PharmD and 3+ years’ experience or equivalent combination of education and experience, and 1 year of SME in respective areas
Current, unrestricted license as a Registered Pharmacist in any state of the United States required.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply concepts of basic algebra and geometry.
To perform this job successfully, an individual should have knowledge of Microsoft Office Suite and a working knowledge of relational databases.

Nice To Haves

Data analysis and claims research experience preferred.
Capability to work with complex systems and analyze data for trends.
Analytical skills with Health Informatics experience preferred.
Experience in promoting disease management or drug cost management programs preferred.

Responsibilities

Serves as a clinical reviewer and provides subject matter support to the Appeals Clinical team.
Able to perform independent research of available medical literature, internal and external guidelines, compendium sources of drug information, and plan benefit documents to render appeal determinations.
Perform retrospective case review for appropriateness as required by management team.
Assist Supervisor with PA audit team and other internal teams to investigate and respond to appeal determination questions relevant to commercial and CMS Part D activity.
Assists the Supervisor with the completion of CMS client audits as needed.
Assists with issues directly related to clinical appeal processing and review as needed.
Develops capability to use all MedImpact systems relevant to the appeal clinical review requirements.
Other duties as assigned including, but not limited to, representing Appeals and Grievance in internal and external meetings related to appeals processing and as approved by management.